Clinical and Experimental Otorhinolaryngology Vol. 7, No. 3: 181-187, September 2014
http://dx.doi.org/10.3342/ceo.2014.7.3.181 pISSN 1976-8710 eISSN 2005-0720
Original Article
Invasive Fungal Sinusitis of the Sphenoid Sinus Dong Hoon Lee1 ∙ Tae Mi Yoon1 ∙ Joon Kyoo Lee1 ∙ Young Eun Joo2 ∙ Kyung Hwa Park3 ∙ Sang Chul Lim1 Department of Otolaryngology-Head and Neck Surgery, 2Research Institute of Medical Sciences, 3Department of Infectious Disease, Chonnam
1
National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
Objective. This study was conducted to present the clinical outcome of invasive fungal sinusitis of the sphenoid sinus and to analyze clinical factors influencing patient survival. Methods. A retrospective review of 12 cases of invasive fungal sphenoiditis was conducted. Results. Cases were divided into acute fulminant invasive fungal spheonoidits (n=4) and chronic invasive fungal sphenoiditis (n=8). The most common underlying disease was diabetes mellitus (n=9). The most common presenting symptoms and signs included visual disturbance (100%). Intracranial extension was observed in 8 patients. Endoscopic debridement and intravenous antifungals were given to all patients. Fatal aneurysmal rupture of the internal carotid artery occurred suddenly in two patients. The mortality rate was 100% for patients with acute fulminant invasive fungal sphenoiditis and 25% for patients with chronic invasive fungal sphenoiditis. In survival analysis, intracranial extension was evaluated as a statistically significant factor (P =0.027). Conclusion. The survival rate of chronic invasive fungal sphenoiditis was 75%. However, the prognosis of acute fulminant invasive fungal sphenoiditis was extremely poor despite the application of aggressive treatment, thus, a high index of suspicion should be required and new diagnostic markers need to be developed for early diagnosis of invasive fungal sinusitis of the sphenoid sinus. Keywords. Invasive, Fungus, Sinusitis, Sphenoid sinus
INTRODUCTION
of immunosuppressive patients with diabetes, hematologic malignancies and prolonged use of steroids. IFS can also occur in immunocompetent hosts [5-8]. In contrast to the non-invasive type which usually has a good prognosis, IFS is considered a potentially lethal condition. Moreover, invasive fungal sphenoiditis is more aggressive than invasive fungal infection of the other paranasal sinuses. This is due to the involvement of important surrounding structures such as the orbital apex, cavernous sinus, optic nerve, internal carotid artery, pituitary gland, and cranial nerves. Patients with early stage sphenoid sinus lesions are usually asymptomatic, thus, the diagnosis is often delayed until they are presented to ear, nose and throat specialists. Because advanced invasive fungal infection of the sphenoid sinus carries significant mortality, early diagnosis and appropriate treatment are crucial for the improvement of patient survival. In this study, we report the clinical features and treatment outcomes of IFS of the sphenoid sinus. In addition, this study also analyzed clinical factors influencing patient survival.
Fungal sinusitis is generally classified into allergic, chronic noninvasive (fungus ball), chronic invasive, granulomatous invasive, and acute fulminant invasive fungal sinusitis based on histological features according to the diagnostic criteria of deShazo et al. [1,2]. In addition to these, other types such as saprophytic colonization [3] and semi-invasive fungal infection [4] have been suggested in the literature. The incidence of invasive fungal sinusitis (IFS) has been increasing due to the increasing number ••Received January 1, 2013 Revised April 3, 2013 Accepted April 3, 2013 ••Corresponding author: Sang Chul Lim Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, 322 Seoyang-ro, Hwasun-eup, Hwasun 519-763, Korea Tel: +82-61-379-8190, Fax: +82-61-379-7761 E-mail: [email protected]
Copyright © 2014 by Korean Society of Otorhinolaryngology-Head and Neck Surgery. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Clinical and Experimental Otorhinolaryngology Vol. 7, No. 3: 181-187, September 2014
MATERIALS AND METHODS Medical records of 12 cases of IFS of the sphenoid sinus registered between 2001 and 2010 at the Chonnam National University Hospital and Hwasun Hospital were reviewed. A retrospective review was conducted to evaluate the underlying diseases, clinical manifestations, radiologic findings, treatment, and prognosis of patients with IFS of the sphenoid sinus. The followup period ranged from 12 days to 55 months with a median of 24 months.
Inclusion criteria Patients with IFS of the sphenoid were included if the lesion in the sphenoid sinus was exclusively involved, or if the main lesion was located in the sphenoid sinus and extended outside the sphenoid sinus into the posterior ethmoid, orbital apex, superior orbital fissure, pterygopalatine fossa, dura, cavernous sinus, and/ or cerebrum. Diagnosis of IFS of the sphenoid sinus was made according to clinical findings such as cranial nerve involvement and the presence of underlying diseases such as diabetes, hematologic disorder, etc. and/or histologic evaluation of the sphenoid sinus mucosa revealing the characteristic morphology of fungi such as Aspergillus or Mucor species. According to Chakrabarti et al. [9], differentiation between the acute IFS and the chronic IFS was done based on the speed of progression of the clinical course; acute IFS refers to disease
http://dx.doi.org/10.3342/ceo.2014.7.3.181 pISSN 1976-8710 eISSN 2005-0720
Original Article
Invasive Fungal Sinusitis of the Sphenoid Sinus Dong Hoon Lee1 ∙ Tae Mi Yoon1 ∙ Joon Kyoo Lee1 ∙ Young Eun Joo2 ∙ Kyung Hwa Park3 ∙ Sang Chul Lim1 Department of Otolaryngology-Head and Neck Surgery, 2Research Institute of Medical Sciences, 3Department of Infectious Disease, Chonnam
1
National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
Objective. This study was conducted to present the clinical outcome of invasive fungal sinusitis of the sphenoid sinus and to analyze clinical factors influencing patient survival. Methods. A retrospective review of 12 cases of invasive fungal sphenoiditis was conducted. Results. Cases were divided into acute fulminant invasive fungal spheonoidits (n=4) and chronic invasive fungal sphenoiditis (n=8). The most common underlying disease was diabetes mellitus (n=9). The most common presenting symptoms and signs included visual disturbance (100%). Intracranial extension was observed in 8 patients. Endoscopic debridement and intravenous antifungals were given to all patients. Fatal aneurysmal rupture of the internal carotid artery occurred suddenly in two patients. The mortality rate was 100% for patients with acute fulminant invasive fungal sphenoiditis and 25% for patients with chronic invasive fungal sphenoiditis. In survival analysis, intracranial extension was evaluated as a statistically significant factor (P =0.027). Conclusion. The survival rate of chronic invasive fungal sphenoiditis was 75%. However, the prognosis of acute fulminant invasive fungal sphenoiditis was extremely poor despite the application of aggressive treatment, thus, a high index of suspicion should be required and new diagnostic markers need to be developed for early diagnosis of invasive fungal sinusitis of the sphenoid sinus. Keywords. Invasive, Fungus, Sinusitis, Sphenoid sinus
INTRODUCTION
of immunosuppressive patients with diabetes, hematologic malignancies and prolonged use of steroids. IFS can also occur in immunocompetent hosts [5-8]. In contrast to the non-invasive type which usually has a good prognosis, IFS is considered a potentially lethal condition. Moreover, invasive fungal sphenoiditis is more aggressive than invasive fungal infection of the other paranasal sinuses. This is due to the involvement of important surrounding structures such as the orbital apex, cavernous sinus, optic nerve, internal carotid artery, pituitary gland, and cranial nerves. Patients with early stage sphenoid sinus lesions are usually asymptomatic, thus, the diagnosis is often delayed until they are presented to ear, nose and throat specialists. Because advanced invasive fungal infection of the sphenoid sinus carries significant mortality, early diagnosis and appropriate treatment are crucial for the improvement of patient survival. In this study, we report the clinical features and treatment outcomes of IFS of the sphenoid sinus. In addition, this study also analyzed clinical factors influencing patient survival.
Fungal sinusitis is generally classified into allergic, chronic noninvasive (fungus ball), chronic invasive, granulomatous invasive, and acute fulminant invasive fungal sinusitis based on histological features according to the diagnostic criteria of deShazo et al. [1,2]. In addition to these, other types such as saprophytic colonization [3] and semi-invasive fungal infection [4] have been suggested in the literature. The incidence of invasive fungal sinusitis (IFS) has been increasing due to the increasing number ••Received January 1, 2013 Revised April 3, 2013 Accepted April 3, 2013 ••Corresponding author: Sang Chul Lim Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, 322 Seoyang-ro, Hwasun-eup, Hwasun 519-763, Korea Tel: +82-61-379-8190, Fax: +82-61-379-7761 E-mail: [email protected]
Copyright © 2014 by Korean Society of Otorhinolaryngology-Head and Neck Surgery. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
181
182
Clinical and Experimental Otorhinolaryngology Vol. 7, No. 3: 181-187, September 2014
MATERIALS AND METHODS Medical records of 12 cases of IFS of the sphenoid sinus registered between 2001 and 2010 at the Chonnam National University Hospital and Hwasun Hospital were reviewed. A retrospective review was conducted to evaluate the underlying diseases, clinical manifestations, radiologic findings, treatment, and prognosis of patients with IFS of the sphenoid sinus. The followup period ranged from 12 days to 55 months with a median of 24 months.
Inclusion criteria Patients with IFS of the sphenoid were included if the lesion in the sphenoid sinus was exclusively involved, or if the main lesion was located in the sphenoid sinus and extended outside the sphenoid sinus into the posterior ethmoid, orbital apex, superior orbital fissure, pterygopalatine fossa, dura, cavernous sinus, and/ or cerebrum. Diagnosis of IFS of the sphenoid sinus was made according to clinical findings such as cranial nerve involvement and the presence of underlying diseases such as diabetes, hematologic disorder, etc. and/or histologic evaluation of the sphenoid sinus mucosa revealing the characteristic morphology of fungi such as Aspergillus or Mucor species. According to Chakrabarti et al. [9], differentiation between the acute IFS and the chronic IFS was done based on the speed of progression of the clinical course; acute IFS refers to disease
